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eco ^ < STATEOFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD W m P UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �B TANK REMOVED d DBA OR FACILITY NAME WH ERE TANK IS INSTALLED: S, Zl/( EF /fir-E/✓ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# LbN-01 I B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. REGULAR ❑ 1 MOTOR VEHICLE FUEL F] 4 OIL B. Q- ❑ 1a=I ED e 3 DIESEL ❑ e AVIATION GAS A. 4 GASOHOL ❑ 2 PETROLEUM F-180 EMPTY ❑ 1 PRODUCT ❑ 16ULEADED ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.0: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C.AND ALL THAT APPLIES IN BOX ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP MATERIAL ❑ 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 06 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 1001: METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑96 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 10D% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MOTftL FS RIRG ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES [—] NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPmNTED a SIGNATUREI LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# �FACILIT,-Y#� TANK# STATE I.D.# ® 'p, PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM 8 (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR90W